'When you hear hoofbeats, think of horses not zebras' - the old adage is well-known to GPs but what should you do when faced with a zebra, not a horse? Consultant cardiologist Professor Robert Tulloh and GP Dr Louise Tulloh kick off our new series with their advice on how to catch Kawasaki disease in general practice.

Give reassurance that nocturnal enuresis (NE) and daytime wetting are quite common and can be treated. Wetting accidents affect one in 12 children, causing social and emotional pressures and family conflict. Recognising that there are known physical contributory factors helps families and children to engage in a treatment programme.

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Exclude urinary tract infection and constipation.

This is especially important if the child presents with sudden onset of daytime wetting or secondary NE – onset occurring after more than six months of being dry.

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Monosymptomatic NE – with no daytime symptoms – should be treated rather than waiting for the child to grow out of it.

Spontaneous resolution is a very slow process and recent research suggests that over the age of seven, only those children with less severe enuresis will overcome bedwetting spontaneously [see reference below]. Some 1% will continue to wet into their teens and adult life.

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Further investigations are indicated for daytime wetting in over-fives. Most daytime wetting is associated with functional disturbances, such as overactive bladder. Further investigation is warranted when there is a history of more than one proven urinary tract infection, when abnormal physical signs are detected, when there is continual dribbling or if previous treatments have failed.

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Frequency and urgency in the day, with or without wetting, is the hallmark of an overactive bladder. This is also a cause of non monosymptomatic NE in about one-third all cases of NE. Children with overactive bladder usually have wet patches of variable size and may awaken after bedwetting.

Maximum voided volumes will be smaller than expected. Measure when the child feels that the bladder is full – not the first morning void. To calculate the expected bladder capacity in ml, use age (in years) x 30 + 30. Good fluid intake and regular toileting can be boosted by anticholinergic (antimuscarinic) medication if appropriate.

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Check what the child is drinking. Inadequate fluid intake during the day reduces bladder capacity and results in thirst and increased drinking in the evening. Six to eight cups of liquid spread across the whole day is recommended.

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Enuresis alarms can be successful for nocturnal enuresis from the age of five, if the child is well motivated and has parental support. The highest success rates are seen in well-supported and motivated children with monosymptomatic NE.

It is important to spend time explaining how to use the alarm and regular follow-up is vital. Successful alarm treatment can result in a long-term cure. Introducing an alarm into a difficult social, behavioural or emotional environment is almost invariably unsuccessful.

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Desmopressin can be useful in the management of monosymptomatic NE. Desmopressin is a synthetic analogue of arginine vasopressin, available in tablet or melt, which reduces urine production for about eight hours. It can be used for children over five with primary NE. It is most effective in older children with normal bladders and overproduction of urine at night, characterised by large wet patches early in the night. It has a rapid action making it a good short-term treatment – for example, when sleeping away from home. Relapse is expected with short-term use but prolonged courses can be used to maintain dryness, especially when alarm therapy is not suitable or has been ineffective.

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When there is secondary NE, this should be assessed and treated in the same way as in primary enuresis. Anxiety and stress can trigger secondary NE but wetting often continues after it has been resolved. Assessment and treatment should be offered to the older age group in an age-appropriate setting using the same treatment modalities as for primary NE.

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Be encouraged that assessment, follow-up and support for families in primary care can lead to successful outcomes. Most PCTs have, or are in the process of setting up, local integrated paediatric continence services, to fulfil the NSF for childhood continence (standard 6). These enable GPs to refer children for ongoing treatment and support, following an initial assessment. For best practice guidelines see www.dh.gov.uk/childrensnsf

ERIC is a national registered charity that provides information and support to younger children, teenagers, parents and professionals on bedwetting (nocturnal enuresis), daytime wetting, constipation and soiling and incontinence in children with special needs.